Percutaneous Closure of a Large, Complex Postinfarct Ventricular Septal Defect

Figures

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  Figure 1. Doppler Assessment and CT Scan of the Aortic Valve Showing Calcific Aortic Stenosis (Left and Middle) Doppler assessments showing mean gradient of 35 mm Hg, aortic valve area of 0.7 cm2, peak velocity of 3.8 m/s, dimensionless index of 0.17, and stroke volume of 44 mL/m2. (Right) Three-dimensional reconstruction of CT scan showing heavily calcified aortic valve with Agatston score of 3,555. CT = computed tomography.

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  Figure 2. Cardiac CT and TEE Showing the VSD (Left) Short-axis view on CT showing raggedy VSD in the anteroapical region. (Middle) Long-axis view on CT showing anteroapical VSD (white arrow) and calcified aortic valve (red arrow). (Right) Long-axis color Doppler view on TEE showing significant left-to-right shunting through the VSD (red arrow). CT = computed tomography; TEE = transesophageal echocardiography; VSD = ventricular septal defect.

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  Figure 3. Intraprocedural Angiographic Views Showing the Complexity of the VSD (Left) Agilis steerable sheath (white arrow) and JR4 catheter (red arrow) in a mother-daughter configuration can be seen in the left ventricle. (Right) Contrast can be seen flowing through the VSD (white arrow), showing its anteroapical location and complex morphology. VSD = ventricular septal defect.

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  Figure 4. Fluoroscopic View Showing Transseptal Venovenous Rail After Crossing the VSD (Left) Guidewire in the pulmonary artery after it has crossed the VSD. (Right) Full venovenous rail (white arrow) can be seen after guidewire is being snared into the inferior vena cava. VSD = ventricular septal defect.

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  Figure 5. Right-to-Left Shunting Across the Iatrogenic ASD Due to Severe Tricuspid Regurgitation Doppler assessment showing right-to-left shunting (white arrow) across the iatrogenic ASD due to severe tricuspid regurgitation resulting from creation of the venovenous rail. ASD = atrial septal defect.

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  Figure 6. Transgastric TEE Views Showing the Guidewire (White Arrow) Crossing the VSD at Different Levels (Left) Initially, the VSD was crossed anteriorly. (Right) On the second attempt, the VSD was crossed posteriorly and coaxially. TEE = transesophageal echocardiography; VSD = ventricular septal defect.

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  Figure 7. Fluoroscopy Showing Ventricular Septal Defect Closure Device (White Arrow) Fully Deployed

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  Figure 8. Cardiac CT and Echocardiography Confirming Positions of the VSD Closure Device and TAVR Valve (Top, Left and Right) Long-axis and short-axis views on CT showing well-positioned Edwards S3 Ultra TAVR valve (red arrow) and VSD closure device (white arrow). (Bottom, Left and Right) Apical 4-chamber and 3-chamber views on TTE showing well-positioned VSD closure device (white arrow). CT = computed tomography; TAVR = transcatheter aortic valve replacement; TTE = transthoracic echocardiography; VSD = ventricular septal defect.